Foreword to the special issue: management science for pandemic prevention, preparedness, and response.

Transforming or tinkering: the world remains unprepared for the next pandemic threat

Pandemic Preparedness and Responses to the 2009 H1N1 Influenza: Crisis Management and Public Policy Insights

Despite the devastating impact of COVID-19 and repeated calls for political commitment to health security, our analysis of 43 manifestos from 16 countries and the European Parliamentary elections revealed that only four parties made specific policy pledges on pandemic prevention, preparedness and response, with six providing brief mentions. The vast majority (33 parties) did not mention pandemic prevention, preparedness and response. When referenced, the pandemic was often framed as a rare, one-off crisis or an economic shock rather than a catalyst for systemic health reform. Some parties used it for political critique or validation of past performance, while others framed preparedness in terms of national security or economic resilience rather than public health. In contrast, manifestos overwhelmingly prioritized healthcare system expansion, equity, and access, with a significant emphasis on universal health coverage, mental health, and workforce development. The findings underscore a stark misalignment between global health priorities and domestic political agenda. Political reluctance to emphasize pandemic prevention, preparedness and response appears to be influenced by pandemic fatigue, voter preferences for forward-looking narratives, and institutional incentives favouring short-term tangible outcomes. This persistent neglect of the pandemic in electoral discourse raises concerns about the global community’s ability to sustain momentum for pandemic resilience. We call for stronger engagement between the global health community and political actors to elevate pandemic prevention, preparedness and response as a strategic, cross-cutting priority for future policymaking.

Eloise Todd: mobilising civil society for pandemic prevention

Effective post-pandemic governance must focus on shared challenges

The Global Fund: replenishment and future-proofing

Since first being detected in Wuhan, China in late December 2019, COVID-19 has demanded a response from all levels of government. While the role of local governments in routine public health functions is well understood-and the response to the pandemic has highlighted the importance of involving local governments in the response to and management of large, multifaceted challenges-their role in pandemic response remains more undefined. Accordingly, to better understand how local governments in cities were involved in the response to the COVID-19 pandemic, we conducted a survey involving cities in the Partnership for Healthy Cities to: (i) understand which levels of government were responsible, accountable, consulted, and informed regarding select pandemic response activities; (ii) document when response activities were implemented; (iii) characterize how challenging response activities were; and (iv) query about future engagement in pandemic and epidemic preparedness. Twenty-five cities from around the world completed the survey and we used descriptive statistics to summarize the urban experience in pandemic response. Our results show that national authorities were responsible and accountable for a majority of the activities considered, but that local governments were also responsible and accountable for key activities-especially risk communication and coordinating with community-based organizations and civil society organizations. Further, most response activities were implemented after COVID-19 had been confirmed in a city, many pandemic response activities proved to be challenging for local authorities, and nearly all local authorities envisioned being more engaged in pandemic preparedness and response following the COVID-19 pandemic. This descriptive research represents an important contribution to an expanding evidence base focused on improving the response to the ongoing COVID-19 pandemic, as well as future outbreaks.

Background The COVID-19 pandemic has had disproportionate impacts across race, social class, and geography. Insufficient attention has been paid to addressing the massive inequities worsened by COVID-19. In July 2020, Partners In Health (PIH) and the University of Global Health Equity (UGHE) delivered a four-module short course, ‘An Equity Approach to Pandemic Preparedness and Response: Emerging Insights from COVID-19 Global Response Leaders.’ Objective We describe the design and use of a case-based, short-course education model to transfer knowledge and skills in equity approaches to pandemic preparedness and response. Methods This course used case studies of Massachusetts and Navajo Nation in the US, and Rwanda to highlight examples of equity-centered pandemic response. Course participants completed a post-session assessment survey after each of the four modules. A mixed-method analysis was conducted to elucidate knowledge acquisition on key topics and assess participants’ experience and satisfaction with the course. Results Forty-four percent of participants identified, ‘Immediate need for skills and information to address COVID-19’ as their primary reason for attending the course. Participants reported that they are very likely (4.75 out of 5) to use the information, tools, or skills from the course in their work. The average score for content-related questions answered correctly was 82–88% for each session. Participants (~70-90%) said their understanding was Excellent or Very Good for each session. Participants expressed a deepened understanding of the importance of prioritizing vulnerable communities and built global solidarity. Conclusion The training contributed to a new level of understanding of the social determinants of health and equity issues surrounding pandemic preparedness and response. This course elucidated the intersection of racism and wealth inequality; the role of the social determinants of health in pandemic preparedness and response; and the impacts of neocolonialism on pandemic response in low- and middle-income countries.

Since the outbreak of COVID-19, the process of considering a treaty for pandemic prevention, preparedness, and response has been entirely led by World Health Organization (WHO) member states. To overcome the fundamental limitations of the International Health Regulations (2005) (IHR 2005) system, it is possible to consider a more comprehensive revision of the IHR, perhaps even more drastic than the 2005 revision. Alternatively, a new fundamental and comprehensive treaty for pandemic response could be considered, independent of any revision of the IHR. The WHO and its member states have chosen the latter option and are now pursuing a two-track legislative process to adopt a new pandemic treaty in parallel with some revisions to the IHR.
 This article examines the international community's efforts to improve international health law for pandemic prevention, preparedness, and response in the wake of the COVID-19 pandemic. To do so, it first examines the failures of international health rules and lessons learned from COVID-19, and then analyzes the progress of the WHO's Member States in revising IHR and negotiating a draft pandemic treaty, as well as the differences in legal basis articles under the WHO’s Constitution. The IHR have not responded effectively to the COVID-19 pandemic, and as Report of the Review Committee on the Functioning of the IHR during the COVID-19 response, revision of the Regulations seems inevitable. However, IHR revision alone are not enought to address the problems that have arisen during the pandemic. While a major revision of the IHR could be considered, it would be more difficult to incorporate new legislation into the existing framework of the IHR to create a harmonized and unified normative framework than to create a new treaty. Furthermore, maintaining the form of the Rules in Article 21 is not the best option, despite the fact that the WHO’s Constitution authorizes the Organization to enter into “conventions or agreements” under Article 19. In this regard, amending the International Health Regulations and creating a new pandemic treaty at the same time is the most effective legislative approach in the current context to prevent, prepare for, and respond to diseases that could cause an international health crisis.
 This article reviews the highlights of ｢the Zero Draft of the WHO convention, agreement or other international instrument on pandemic prevention, preparedness and response (“WHO CA+”)｣, published in February 2023, for consideration by the Intergovernmental Negotiating Body (INB). The Zero Draft provides a framework for legal regulation at all levels of the pandemic response and is extensive in its substantive content. The Zero Draft emphasizes equity at all levels and provides concrete measures to achieve it. It covers and documents many issues relevant to pandemic governance, from crisis-resilient health systems and a strong health workforce to measures related to one health and antibiotic resistance, health literacy, and even social determinants of health. The Zero Draft is completely open-ended, meaning that it could change over the course of future negotiations, but it is unlikely to change much in terms of the main content that will be included in a pandemic treaty.

The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95% uncertainty interval [UI] 9·1-9·3) was spent on health worldwide. We found great disparities in the amount of resources devoted to health, with high-income countries spending $7·3 trillion (95% UI 7·2-7·4) in 2019; 293·7 times the $24·8 billion (95% UI 24·3-25·3) spent by low-income countries in 2019. That same year, $43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and $37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11-21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained. Bill & Melinda Gates Foundation.

The importance of pandemic preparedness is underscored by two recent and significant findings in the US, including outbreaks of measles in children and adults, as well as the demonstration of airborne transmission of the influenza A(H5N1) virus (bird flu). On June 1, 2024, the 77th World Health Assembly of the World Health Organization (WHO) reached a consensus on amendments to the 2005 International Health Regulations, representing a new universal legal framework for global health, pandemic preparedness, and response that will enter into force in September 2025. On May 20, 2025, the 78th World Health Assembly of the WHO adopted the Pandemic Agreement, following three years of negotiations that identified gaps and inequities in the global response to the COVID-19 pandemic. The WHO Pandemic Agreement document outlines the principles, approaches, and tools to enhance international coordination for pandemic prevention, preparedness, and response, including equitable access to vaccines, diagnostics, and therapeutics. This editorial aims to highlight the timeliness of the 2025 WHO Pandemic Agreement and the 2024 amendments to the International Health Regulations, as well as the need for improved pandemic preparedness and response at this time.

As the world comes together through the WHO design and consultation process on a new medical counter-measures platform, we propose an enhanced APT-A (Access to Pandemic Tools Accelerator) that builds on the previous architecture but includes two new pillars - one for economic assistance and another to combat structural inequalities for future pandemic preparedness and response. As part of the APT-A, and in light of the Independent Panel on Pandemic Preparation & Response's call for an enhanced end-to-end platform for access to essential health technologies, we propose a new mechanism that we call the Pandemic Open Technology Access Accelerator (POTAX) that can be implemented through the medical countermeasures platform and the pandemic accord currently under negotiation through the World Health Assembly and supported by the High-Level Meeting review on Pandemic Prevention, Preparedness, and Response at the United Nations. This mechanism will provide (1) conditional financing for new vaccines and other essential health technologies requiring companies to vest licenses in POTAX and pool intellectual property and other data necessary to allow equitable access to the resulting technologies. It will also (2) support collective procurement as well as measures to ensure equitable distribution and uptake of these technologies.

On 24 April 2009 the World Health Organization (WHO) reported human cases of swine influenza A/H1N1 occurring in the USA and Mexico.1 The number of recorded cases increased rapidly, there was clear human to human transmission,2 and it appears that the outbreak originated in Mexico in mid-March or earlier.3 This prompted WHO on 27th April to raise its pandemic preparedness from phase three, where it had been for some time as a result of the ongoing H5N1 virus epizootic, first to phase 42 and then 2 days later to phase 5.4 Countries with national pandemic plans responded accordingly. It might be argued that by the end of May the spread of this new virus has been sufficient for WHO to declare that phase 6, a pandemic, had been reached. However, most of the recent pandemic preparedness planning has been initiated and refined in the face of the perceived threat of a severe outbreak due to a virus such as the H5N1 subtype. In fact most such plans have an introduction or preamble explaining, for those less familiar with influenza, that there are two types of antigenic variation in human influenza, ‘antigenic drift’, due to small ongoing mutational changes and ‘antigenic shift’ when a novel influenza A subtype successfully enters and transmits in the human population and that this is when pandemic influenza results. True to the frequent description of influenza as enigmatic or unpredictable this new outbreak represents neither antigenic shift nor antigenic drift and whether this should truly be considered a pandemic is not yet clearcut.5 In this issue of Influenza and Other Respiratory Viruses there are a number of articles related to the current outbreak and to pandemic preparedness and response. Tracking the virus is clearly important in attempts to contain spread and the article by Hurt et al.6 provides a preliminary assessment of rapid point of care tests for the detection of the novel H1N1 virus. Kelly et al.7 demonstrate that the age distribution of outbreaks due to this virus to date, in the USA and Europe, is similar to that of seasonal A(H1N1) when compared with recent outbreaks in Australia and suggest that this may be an inherent property of A(H1N1) viruses. McCaw et al.8 speculate that a variety of factors that influence both the susceptibility of populations and the fitness of circulating influenza viruses could explain the varying mortality rates experienced in the 1918–1919 pandemic. These may be important in responding to the current outbreak as continued out of season activity in the Northern hemisphere and ongoing geographic spread may be an indication that this novel H1N1 has true pandemic potential. As we move into the Southern hemisphere winter it remains to be seen whether season may influence the impact of the virus and whether certain populations are at increased risk as suggested by the initial, apparently greater severity in Mexico. While WHO is yet to recommend commercial manufacture of a vaccine against the novel H1N1 virus, news reports indicate that many European countries, the USA and Australia have already placed orders for vaccine. The article by Hessel on behalf of the European Vaccine Manufacturers9 reviews current progress in meeting the challenges of pandemic influenza vaccine manufacture, however, as has been frequently emphasised in the past and again recently in the context of the current outbreak,10, the lead-time for influenza vaccine manufacture and global production capacity seem destined to fail global demands for both timeliness and quantity of supply for a pandemic occurring in the immediate future. The Holy Grail for influenza scientists has long been a vaccine that could produce heterotypic protection across all influenza A viruses. An encouraging approach targeting T-cell immunity with lipopeptide vaccines that may reduce the severity of disease and supplement the antibody-based approach to vaccination is reported by Ng et al.11 If such vaccines are effective in practice their value globally will clearly be dependent on a number of factors including cost, duration of immunity and availability, particularly for developing countries. The World Health Organization recommends that all countries should develop a pandemic preparedness plan as part of the implementation of the International Health Regulations.12 However, web-based documents13,14 provide evidence of only 45 such plans and it appears that some countries, particularly developing countries, have yet to complete a pandemic plan. Clearly, for those countries with little capacity to directly source vaccines or antivirals as a part of their pandemic response, preparedness planning requires special considerations15 including an emphasis on non-pharmaceutical interventions.16 The current emergence of a novel virus, be it a pandemic virus or not, places additional emphasis on the need for pandemic preparedness planning and the article by Azziz-Baumgartner et al.17 provides a valuable overview of a process for drafting a plan. In his review article, in this issue,18 David Fedson observes that ‘most of the world’s people will not have access to affordable supplies of vaccines and antivirals’ and that ‘In the 21st century, science ought to be able to provide something better’. He proposes that understanding the system-wide effects of influenza on the host that are responsible for the severe consequences of pandemic influenza, particularly the increased mortality in younger adults, may provide a basis for ameliorating these effects with inexpensive generic agents that are readily available even in developing countries. The current outbreak may provide an ideal opportunity to test these and other approaches to minimising the impact of a pandemic. And we must remember that while we are distracted with the H1N1 outbreak the H5N1 epizootic continues and the number of human cases continues to rise, particularly in Egypt. Wouldn't it be a terrible irony if H5N1 suddenly achieved the ability to transmit readily in humans, possibly aided by widespread infection of H1N1 and increased opportunity for reassortment, with much of our resources already committed to H1N1. Influenza may yet hold more surprises. As the World Health Organization and the scientific community ponder whether the current outbreak constitutes a pandemic and the appropriate level of response to it, an additional area of confusion has become apparent – how should we refer to it, particularly as it doesn’t represent a novel subtype? Official communications and scientific reports, including those included in this issue of this journal, already contain a confusing array of nomenclature. These include ‘swine influenza’, ‘novel swine-origin H1N1 influenza’ and ‘human-swine influenza’. Recently it seems that it is considered inappropriate to include the word ‘swine’ in referring to the virus and it has become ‘novel influenza A(H1N1)’ and currently ‘influenza A(H1N1)v’ (v for variant). The latter gives no hint as to its origin or uniqueness, is very bland and seems unlikely to resonate with the popular media many of whom, probably by analogy with referring to H5N1 as ‘bird flu’, continue to use ‘swine flu’ or ‘pig flu’ when reporting this outbreak. From a scientific standpoint there is, of course, nothing novel about the circulation of ‘variant’ influenza viruses. The journal will continue to fast-track reports related to the current outbreak, the global response and pandemic preparedness and response generally, as it has for this issue and welcomes contributions.

Reconceptualizing successful pandemic preparedness and response: A feminist perspective

Backsliding on human rights and equity in the Pandemic Accord